SAY THE WORD ‘resilient’ and many of us will think of the incredible achievements of yachtswoman Dame Ellen MacArthur. MacArthur recently completed 27,354 miles in 71 days, 14 hours, 18 minutes and 33 seconds to become the fastest person to solo circumnavigate the globe. Hearing MacArthur talk about her journey, it was clear that she had to draw upon all her inner strengths to meet every challenge that the elements could pit against her from icebergs to hailstorms to becalmed seas. As an 18-year-old MacArthur sailed alone around Britain. By the age of 24 she was competing in the Vendée Globe, the toughest single-handed race, finishing second after overcoming two near-disasters. In the seventh week of her latest global race, MacArthur had to climb the 100ft mast of her trimaran to repair a damaged hoist mechanism. The repair work and the necessity of turning back away from the wind in order to steady the boat cost her time and also stretched her physically to the limit. Yet she continued. MacArthur demonstrates that she has the resilience to handle setbacks and keep fighting to reach her goals. Resilience is the ability of people to bounce back quickly in the face of the many pressures and adversities they may encounter in today’s world. Studies show that the more resilient you become the harder you will try when things get difficult and the more likely you are to succeed. Resilience is not just important for athletes, think of businessman Stelios Haji-Ioannou who despite being told that his concept of a no frills airline would never fly now has a burgeoning empire ranging from pizzas to male grooming products. Now can you think of somebody you know that is resilient – do they display similar traits to MacArthur and Haji-Ioannou. Faced with setbacks – such as changed market economics or a day filled with disappointing meetings – how do they deal with the obstacles they face? Healthcare sales is a highly competitive pressured market which has seen R&D costs spiral while some patents have expired, enabling new companies to enter the market offering cheaper generic products without the overheads of product research. Merck, for example, will see its patent on Zocor expire in 2006. As a professional pharmaceutical sales representative this can mean competing on an uneven playing field. By the same token, the tender process for high value equipment contracts can last for several years, so companies who have not been effective in the sales process can find themselves out of the picture for a long period of time. Time with doctors, consultants and purchasing managers is at a premium and securing a meeting can be a hurdle in itself. Mario Monella, a medical sales representative with specialist sales organisation, In2Focus, comments: “The colleagues I have observed who are successful, are the ones who are highly motivated and demonstrate high levels of innovation in finding ways to get in to see potential clients. They also have good communication skills and are able to talk to the Doctors and consultants on the same level.” Sales professionals within the pharmaceutical and healthcare industry faced with this myriad of obstacles and setbacks need to be just like Ellen MacArthur and utilise their resources and their resilient traits in order to succeed. So how resilient are you? Research conducted by Dr. Martin E. P. Seligman (University of Pennsylvania Professor of Psychology) and other top psychologists worldwide explored the thought process of successful people. This research found that it is resilience above anything else that determines who succeeds and who fails when faced with the day-to-day obstacles and setbacks. Further work carried out by renowned psychologist Andrew Shatte and Karen Reivich PhD’s in to resilience showed that there are seven behaviours or ‘inner strengths’, which can be measured and developed. These inner strengths are not rocket science, but are thoughts and feelings that you will recognise as part of your own make-up. Firstly, Emotion Regulation, this is the ability to control your emotions in the midst of an adversity so that you are able to accomplish your goals. So for example, a newly recruited sales representative making four unsuccessful calls in a row needs to not allow him/herself to feel anxious approaching the fifth call. Impulse Control, in the midst of an adversity it is important to be able to control our impulses – resilient people are able to control these. In the example above, the first thought may be to give up for the day; by controlling these impulses the resilient person will overcome the earlier setbacks. The ability to accurately and comprehensively identify the causes of your problem, and then identify and enact solutions that solve the problem is termed Causal Analysis. This is closely linked with Self-efficacy, the extent to which you believe in yourself and your ability to take care of most of the obstacles and setbacks you face daily. We all want to be optimistic, but optimism needs to be realistic. One of the skills is Realistic Optimism – this is about maintaining a realistic view of your world. Optimism is something we all need in order to be motivated and charged. Empathy is the ability to decode the nonverbal cues that people use to communicate such as facial expressions, body language and tones of voice. This is closely linked to the final behaviour, Reaching Out, the ability to take on new opportunities and challenges in order to maximise your potential, and to deepen your relationships with those important in not just in your business but also family life. These skills and abilities are crucial to you as part of an industry that is built on personal relationships requiring in-depth knowledge and trust. Once an individual has a better understanding of their levels of resilience they can then develop the skills that enable them to change the way they approach and handle situations. In doing so they can boost their abilities to maximise the potential of opportunities and not allow setbacks to become obstacles to success. Monella adds: “If I experience a series of unsuccessful calls, I am motivated to get a positive outcome with the next call.” Thinking about his own resilience, Monella concludes that having survived as a passenger in a serious car crash as a teenager, he was motivated to see major setbacks as challenges. When told he would never run again he strove to prove doctors wrong and went on to play football, attend university and captain his boxing team. He has carried these resilient thought processes in to a very successful career. Whether you are new or have been in the business for several years, or if you have the responsibility of managing others, a key element of your success will be how resilient you and your colleagues are. Clearly, not everyone can sail single-handed around the world, but by arming yourselves with the skills that you need to succeed you will be able to achieve your targets and goals. This will result in more successful sales calls and higher earnings. Now you can learn to develop those resilient skills that are necessary to achieve success just like Stelios and MacArthur.

• financial stability of the Trusts
• Foundation Hospitals http://www.nhis.info/display/display.asp?id=83#link854 - with interest on the fundamental viability of the establishments with the unknowns raised by the Agenda for Change http://www.nhis.info/display/display.asp?id=239#link1282 , the new contract for consultants, Payment by Results and the advent of the Choice http://www.nhis.info/display/display.asp?id=248#link1284 programme
• the postcode lottery - highlighted by variations in the treatment of cancer patients http://www.nhis.info/display/display.asp?id=10#link144. However with increasing autonomy at the local level and a weakening of control from the centre - local differences are inevitable
• the use of the private finance initiative http://www.nhis.info/display/display.asp?id=66. in the building of hospitals - strongly resisted by the Unions
• the running of NHS services by the independent sector - in particular its running of Diagnostic and Treatment Centres http://www.nhis.info/display/display.asp?id=33#link625 (DTCs) leading to the accusation of creeping privatisation of the NHS
• the continued existence of waiting lists http://www.nhis.info/display/display.asp?id=74
• the treatment of patients with long-term conditions http://www.nhis.info/display/display.asp?id=12#link1175. These represent the major healthcare costs and improvements in their care would significantly alter the public's perception of the effectiveness of the NHS.

For the NHS a key issue driving change is the advent of Practice-based Commissioning http://www.nhis.info/display/display.asp?id=31#link1310 because how GPs carry out this role will determine how many of the above forces interplay. The underlying tensions of the return to a NHS Marketplace was well discussed in a Guardian article - see http://society.guardian.co.uk/nhsplan/story/0,7991,1398287,00.html. In January, the following deadlines were scaled back:

• the implementation of dental care reform
• the advent of Payment by Results

With a deal of criticism about the proposed content of the new Mental Health Act, the subject has been very much in the news. A new group has been set up to look at and advise on options, but that will not be easy. There was also a suicide prevention strategy, an action plan to achieve equality in mental healthcare for ethnic minorities and an offender mental health care pathway http://www.nhis.info/nhis_resources/DMenHealthPrisonPathway.pdf for those involved in the criminal justice system. Also:

• the government published a response to a critical report on allergy services
• a report was published on improving lives for the disabled - together with a 20 years vision
• better access was promised to medicine safety data
• the IT programme published a deployment schedule
• pharmacy statistics were published
• a consultation was started on reimbursement of generic medicines.

Quite a busy month! If you have problems or want to know more, email info@nhis.info.

Shifting patients from secondary to primary care The NHS Modernisation Agency produced a document last August entitled “10 High Impact Changes for Service Improvement and Delivery” (www.natpact.nhs.uk), which they insist are all patient centred. Casting an eye over these it is intriguing to see how they link inextricably with taking the pressure off Secondary care and putting the onus on improving and developing levels of patient care in the Primary sector. I would like to look at just five of them with their respective links:

• “Treating day surgery as the norm for elective surgery could release nearly half a million in patient bed days each year” – more aftercare into the Primary care sector and link to the Practice Based Commissioning (PbC) of elective care.
• “Improving patient flow across the whole NHS by improving access to key diagnostic tests could save 25 million weeks of unnecessary patient waiting time” – the link to local Treatment Centres (TCs), whether NHS or independently run, and Practice Based Commissioning (PbC) of diagnostic tests is indisputable.
• “Avoiding unnecessary Follow-Ups (FU’s) for patients and providing necessary FU’s in the right care setting could save half a million appointments in just Orthopaedics, ENT, Ophthalmology and Dermatology” – linking directly with PbC, Consultant run clinics and the GP with Special Interest (GPwSI)). I spoke to a local surgery only yesterday who have a GP currently training in Dermatology. This could provide a useful Local Enhanced Service to all patients in the locality (and increased earnings for the surgery) but their concern is how will the other partners cope with the increased number of patient consultations etc in the regular absence of a full time partner?
• “Optimising patient flow through service bottlenecks using process templates could free up 15-20% of current capacity to address waiting time” – linking to PbC and ‘patient choice’ (a driver for quality and empowerment – DoH Dec 04). Interestingly in January 2005 John Reid announced a £95 million boost for e-booking and patient choice. PCTs that offer a choice of hospital treatment to NHS patients through the new electronic ‘Choose and Book’ system will be financially rewarded. The Government promise is that by 31st December 05 all patients will be offered a choice of four or five providers when referred by a GP. In order to achieve this target these funds will be paid in three stages, Stage 1 if GP practices install the Choose & Book system by 30 June 05, Stage 2 when they actually use the system for 50% of their referrals by the end of October 05, and Stage 3 when GPs use the system for 90% of patient referrals by 2006. Capital funds will be allocated to successful PCTs and they in turn will decide how to use the money to meet locally determined needs.
• “Applying systematic approach to care for people with long term conditions could prevent a quarter of a million emergency admissions to hospital” – this is my favourite as it screams ‘Chronic Disease Management’ and takes us directly back to the nGMS contract, and the infamous Quality and Outcomes Framework (QOF) incorporating the 10 Chronic Disease Management areas that we all now know and love!

Chronic Disease Management: why is it so important?

1. 80% of primary care consultations AND all healthcare spend relate to managing patients with long term conditions
2. Co-morbidity (patients with more than one long term condition) costs six times more than one ‘normal’ patient
3. Patients with long term conditions utilise over 60% of hospital bed days
4. There are 17.5 million adults with chronic disease in the UK, 45% of them have more than one, and by 2030 this will double in the 65 and over age bracket.

Managing long term conditions and Practice based commissioning (PbC)
  The introduction of PbC will encourage GPs to use complete ‘packages of care’ and education for patients with long terms conditions. The plan is to divide these patients into three levels of risk:
Level One – 70-80% of patients – ‘Supportive Care & Self Care’– linking with the Expert Patient Programme in Primary Care and Government health campaigns. Level Two – higher risk patients – ‘Specialist Disease Management’ – linking with Chronic Disease Management registers, nGMS contract and QOF, National Service Frameworks and NICE in primary care. These patients are now being more actively managed e.g. via QOF indicators, as they are regularly recalled for health checks. This active management should help keep patients with chronic diseases stable for longer, and out of hospital. Level Three – ‘patients with highly complex conditions requiring Case Management’ – linking with key workers such as Specialist Nurses and Community Matrons in Primary Care. This will help reduce the number of admissions for these patients , and ensure when they are admitted, that it is for as short a time as possible.   This neatly links into John Reid’s announcement on 5th January 2005 of the new role of the Community Matron, 3000 of whom will be in place by March 2007 and will take on a central role developing personalised care plans, initiating tests, prescribing and carrying out medication reviews for patients at level 3, who only account for 5% of the CDM patients but occupy nearly 50% of hospital beds for emergency admissions. Although currently the QOF is improving CDM, Community Matrons hopefully will reduce the GP workload AND reduce the number of emergency bed days by 5%. The Royal College of GPs however suggest that if this is to work, the Community Matrons must be based in GP surgeries under the supervision of the GPs who are ultimately responsible for their own patients. Community matrons is one of a series of recommendations within the NSF (National Service Framework) for Long-term Conditions, to be published later this year, a blueprint for care for these patients, aiming at driving up quality (and pegging back costs). Pressures in the surgery   So – taking you back to your GP customers in Primary Care, is it any wonder that there are uncertainties and many unanswered questions. Over the last 12 months they have had to cope with the nGMS Contract, setting of Aspirational points, the demands of the QOF, linking to QMAS (Quality Management & Analysis System) to calculate QOF points and all the related IT problems, examining the skill mix of staff to enable them to achieve their targets, the QOF visit teams between October and January, National Disease Prevalence Day (14th Feb), National Achievement Day (31st March 05 when all QOF points are calculated) – not to mention Agenda for change (new terms and conditions for NHS staff) and now Practice Based Commissioning which launches on 1st April 2005, whether to use the ‘Choose and Book’ system and finally, preparing for Year Two nGMS involving review of the QOF Visit Team reports & recommendations, and practice development planning to deliver better services, skill mix etc to maximise points and develop the practice capability to take on more secondary care workload . . . Practice based commissioning – April 2005 At the time of going to print , we are still awaiting the Technical Guidance from the Government on Practice Based Commissioning. This will cover budget setting, reasonable management costs and PCT contingency funds. However since Paul Midgley’s comprehensive PF article on PbC (October 2004), a few additional points have come to light.

1. DoH to support installation and application of IT schemes along with Development Programme for Practice Management
2. No huge expansion in bureaucracy as PCTs retain legal responsibility for budgets and contracting
3. No return to hospital bargaining as with GP Fundholding as there will be a single National Tariff. This connects to the idea that money should follow the patient (Payment by Results). Each procedure has been costed nationally, and will apply to all elective procedures from April 2005. From 2006 it will also apply to A&E, Outpatients and emergency admissions and procedures. The relevance to PbC is that it enables a locality to look at the tariff and see if they can offer the same service for less and commission from themselves (and offer to surrounding GPs).
4. Choose and Book to enable patients to book appointments with hospitals from the surgery, see above.
5. Savings – initially this was 50% to surgery and 50% to PCT. This has now changed to 100% savings to the Surgery/locality BUT monies must be spent on improving service to patients i.e. employing Specialist Nurses or Consultants to run clinics, paying for GPs to train in Special Interests, one-stop clinics for certain conditions, the setting up of urgent care centres that combine out-of-hours services with dispensing and lab tests. All spending of savings will be subject to approval by both the PEC and the PCT. However, the revised guidance now gives the PCTs power to top slice some of the budget incase of overspend by the surgeries in their locality.

Practice based or locality commissioning? Surgeries may be better off joining forces to cut down on risk (e.g. of going over budget because of a few very expensive patients), which could also improve clinical quality. Concerns exist over balancing budgets over three years as there may be a lack of management experience to cope with this. Could the weighted capitation formula to be introduced to calculate budgets provide some low-referring practices with financial windfalls? (Initially budgets will be based on historical referral patterns). Other concerns amongst GPs and PCTs include the possible impact on equity as not all PCTs are ready (developmental, manpower and financial issues) to develop local service alternatives, many acute trusts cannot supply accurate activity data linked to individual referrers, which could result in imperfect budget setting and inappropriate resource allocation. So the first year of PbC may well include an element of data verification within PCT incentive schemes. Finally, there is the small matter of GP time and enthusiasm . . and PCTs having the experience and management staff in post to help manage PbC. Spinning plates – more income, more services, more satisfaction? Through all this the GP needs to focus on services that will provide a direct link between PbC and improving patient choice, Chronic Disease Management, and the earning potential of the Quality & Outcomes Framework, which will not only increase Surgery income, but by their very nature improve the quality of care to patients. I will finish with two quotes, the first from East Devon PCT already involved in PbC and the second from a GP in the same area – “GPs are in the best position to know what services their patients need. PbC is about enabling, empowering and providing incentives for them to think more about referral patterns, understand the underlying cost implications and use this data to explore how things can be done differently to benefit the patient” “Overall, devolved budgets will mean we are no longer working within the confines of traditional practice budgets. They will give us the freedom and the potential savings we need to make real changes for our own patients in our own communities”. So what does this all mean to YOU?

1. Local knowledge is power in relationship building with your customers as they build up locality-based alternatives to secondary care through PbC and Local Enhanced Services. See www.nhis.info for the latest information on local and national developments published on the web.
2. Increased prescribing in primary care is inevitable – watch out for
   • Treatment Centres (80 across UK by end of 2005)
   • Community Matrons (3000 by 2007), with prescribing power
   • Specialist Nurses in locality bases e.g. Diabetes etc with prescribing power
   • GPwSI e.g. Dermatology, Diabetes, ENT, Orthopaedics etc
   • Locally run Consultant Clinics
3. Continuing focus on Chronic Disease Management – QOF points increase in value by 60% from April 2005 - think about value added services to help practices achieve points (e.g. contact Healthcare Partnership). Some QOF indicators will change in April 2006, Obesity is to be included, and practices will want to prepare for this in 2005.
4. Appreciation that GPs will have even less time to spend with you, so make it worth their while (and yours), discover your customers needs, and target the right customers. Move away from chasing numbers, instead give customers what they want and need. Find out the practice’s needs by talking with the practice manager. Support practice-based learning activity e.g. PPDP meetings in Protected Learning Time and design events with your customers rather than offering off the shelf packages. Your networking skills are key!

THE CURRENT ENVIRONMENT Pharma companies are indeed caught between the Devil and the Deep Blue Sea. Sometimes, it seems, whatever your organisation does, someone, somewhere will criticise your thoughts, words and deeds. A representative once told me that an NHS customer compared them to the tobacco industry!! Selling drugs with serious side effects for lucrative profit and no other considerations!! Why do opinions like this exist? We, the NHS use your drugs to save lives, treat diseases and reduce suffering. So why are Pharma facing such backlashes from the public, customers and even regulatory authorities? Maybe this is why the Government has requested the Health Select Committee to carry out an Enquiry into the influence of the Pharmaceutical Industry within the UK WHAT WILL THE HOUSE OF COMMONS LOOK INTO? There are six main areas that the government want to investigate:

1. Drug Innovation – how and why new drugs get discovered, and what drives choice and area of research (ie) – from antibiotics to female sexual dysfunction
2. Medical Research Conduct – in depth report on UK clinical trials process and research with drug therapies
3. Medical Information – this will be significant. Not only covering the mechanisms of pharmaceutical company medical information to patients, public and healthcare professionals, but will also encompass promotion and marketing. I suspect this will be far reaching – every thing from how you disseminate information to how I receive it. Just think of all the times you have had sales materials recalled, or been told you can/can’t say or provide information. Interestingly, not only is the ABPI is carrying out it’s own consultation but so is Europe.
4. Educational Programmes – we all know Pharma organise/sponsor the majority of the educational events undertaken by GPs, nurses and healthcare professionals. Increasingly, we are now seeing significant involovement in patient awareness programmes. Whilst education is vital, the whole issue of whether a Drug Company Lunch is education or promotion is an interesting concept . . .
5. Drug Safety & Regulation – I don’t think I have ever seen such tacit times. Drug safety (statins, SSRIs), license withdrawal (one COX-II already, maybe others to follow) and significant difficulties/failure to achieve license in the UK (Pfizer’s antidepressant, AZ’s antithrombotic) seems to suggest that the whole regulatory arena is becoming a significant thorn in the side of Pharmaceutical Companies. The government will report on the exact relationships between the MHRA (Medicines Healthcare Regulatory Agency) and Pharmaceutical Companies and the nature of European Member State Approval / EU Licensing. This topic has already received significant media attention and TV coverage.
6. Value of Products – All medicines are cost effective (aren’t they?). Well that’s what reps tell me anyway. They all tell me that all their drugs are cost effective. So in theory anyway, there are not any products being marketed that are NOT cost effective. Well this will also be part of this enquiry. Does the Pharmaceutical Industry offer value for money . . This will be interesting.

THE VIEW FROM THE ABPI Interestingly, the ABPI has said it ‘welcomes’ the announcement from the House of Commons that a Government Enquiry is taking place. They go on to say they look forward to ‘co-operating fully’ with the committee as the enquiry proceeds. (I guess they had to ‘welcome’ the announcement and they probably would want ‘involvement’ in this enquiry. That is as long it does not result in another report entitled The Influence of the ABPI on the House of Commons Health Select Committee Enquiry on the Influence of the Pharmaceutical Industry!) Just think about these topics. Maybe more importantly – why is this happening now? Maybe this enquiry will once and for all admonish Pharma as the good guys. Or will it get very heavy with further reports and recommendations? What I find fascinating is that The Matrix USUALLY writes about the changes in the NHS and its impact on the Pharmaceutical Industry. This article is unusual in that I am beginning to realise this enquiry will result in changes within the Pharmaceutical Industry which in turn will have an impact on the NHS!

OMAR ALI is the Formulary Development Pharmacist for Surrey and Sussex Healthcare NHS Trust and is a PCT Formulary Adviser to 2 PCTs. He is a lecturer on the MSc on Pharmacy Practice at Portsmouth University and is also an adviser to three Drugs and Therapeutics Committees in the South of England. Omar is a National Speaker in the UK (cardiovascular, diabetes, mental health) and is an Executive Board Member for the National Obesity Forum. He can be reached directly on ‘alipha@aol.com’

The response from our readers was again fantastic, with 1,503 replies and, as with all such exercises, it is the changes from year to year that provide the most interesting results, since they can give useful early clues to industry trends. As before, the objectives of the survey were to provide some understanding of:

• The selection of employers of choice
• The motivation of individuals
• Their levels of satisfaction
• Total remuneration packages
• Recruitment trends
• The work / life balance of medical representatives

To define the responder profile, the salient details are given in this table:

Employers Of Choice 2004 Respondents were asked to rate companies, not including their own employer, in terms of their perceived desirability to work for, giving scores from very high desirability to very low desirability. As shown in this table, this showed some major changes compared with earlier years.

The key findings in 2004 were:

• Eli Lilly is the employer of choice for the second year having been second three years ago – a really remarkable achievement!
• Boehringer Ingelheim climbed to second place and there were two debutantes in the “top-ten,” namely Schering Health and Procter and Gamble.
• Pfizer and GlaxoSmithKline have dropped out of the ten, in spite of both being in the first three spots in 2002 and 2003.

This part of the survey poses many questions. Clearly the smaller companies are below the radar scan of most responders, with the majority scoring ‘no opinion’, but the change in perception as far as two market leaders are concerned need some investigation. If we take only the positive perceptions of companies into consideration then not much would have changed from 2003 with Pfizer in second place and GlaxoSmithKline at sixth. But the assessment of company of choice is a balance between positive and negative perceptions. For whatever reason, the negative perceptions concerning these two companies have grown to such an extent that the net effect has been to rob them of a top ten position.
Motivation and Satisfaction Responders were asked what was important to them in terms of an ideal working environment and how satisfied they currently were over a range of fifteen motivational factors. The results for four employment categories were:

KEY: Belief = Belief in present products sold; Manager = Relationship with your manager; Car = Car policy; Security = Job security; Shares = Share scheme; Appraisals = Structured appraisal systems; Autonomy = Autonomy in role; Development = Personal development; Recognition = Recognition of your success; Pension = Pension Scheme; Accountability = Individual Accountability for Sales As always, salary is key to motivation, because that’s why we work. Relations with one’s manger feature strongly because, if they are bad, life isn’t worth living and, for the front line sales people, product belief is paramount. The survey shows that there’s little problem with the manager and belief questions. However, satisfaction with the product pipeline, which was in the top three in the most satisfied section last year, is absent for all categories, so are there growing general worries about pipeline viability? The real gripes are with bonuses, although its highest motivation ranking is sixth, and increasingly with share schemes although, again, shares to not appear as a motivating high. So such things with which you are dissatisfied are not key factors.
Remuneration The remuneration survey actually showed the most telling result. The table shows average salary as a percentage of the average national earnings – and this excludes any car benefit that you may have – together with the average salary increase over last year and the average monthly bonus. Last year’s review expressed surprise that, in spite of the relative affluence, less than half of the industry thought they were well off! This year the largest movement has been in the perception of the appropriateness of the remuneration package. And, as can be seen, there are some remarkable changes.

This could be interpreted as a sign of the maturing of the industry. In general you believe in what you are selling, you have little trouble with the boss, and although the odd extra cash would not go amiss, you are beginning to realise that by and large, you are pretty well off.

SCIENTISTS FEAR that the bird flu virus could merge with a human flu virus. This might result in a new, fatal flu virus that could be passed rapidly from person to person with potentially devastating results. To keep the outbreak of bird flu virus under control, many of the Asian countries are culling their poultry stocks to prevent further spread of the virus. What is bird flu? Avian refers to birds and flu is the common name for influenza. Avian flu is influenza that infects birds, including wild birds such as ducks and domestic birds such as chickens. Avian flu is caused by influenza virus type A. There are 15 subtypes influenza A, two of which affect birds. These are called the H5 and the H7 subtypes.1 These viruses are known as “highly pathogenic (disease-causing) avian influenza” (HPAI). They produce a severe disease in birds and are rapidly fatal, leading to bird flu epidemics. One such bird flu virus (the H5N1 subtype) is currently infecting chickens in Asian countries. Why are we so concerned about bird flu? The bird flu virus can occasionally jump between species and infect people who have been in close contact with infected birds¹. Most people who catch bird flu become very ill or die. As of 28th January 2005, 55 people in Asia have been infected with bird flu and 42 of these people have died². How is bird flu virus passed from birds to people? When a bird is infected with bird flu, it sheds the flu virus in its faeces, saliva and mucus. Other birds become infected by eating or inhaling the virus. The virus can infect people who are in close contact with infected birds - for example by people inhaling dried faeces that have become trampled into dust or stuck to the feathers or other parts of the body of the infected bird¹. People cannot catch bird flu from eating cooked chickens. Can bird flu be passed from person to person? The ability of bird flu viruses to infect humans throws up this worrying possibility. A bird flu virus could merge with a human flu virus to create a new virus. This new virus could then be passed between humans. If this happens with a highly pathogenic avian influenza virus, the result could be a pandemic of highly contagious flu. What is a flu pandemic? When a new, highly infectious form of a flu virus is formed it can rapidly infect a large number of people. The result is an illness that rapidly spreads round the world and may cause widespread loss of life. An example is the Spanish flu pandemic of 1918-1919 which caused an estimated 40-50 million deaths worldwide³. How can bird flu and human flu viruses merge? There are two ways in which a bird flu virus could merge with a human flu virus, creating a new virus that can be easily passed between humans: In humans- if a person who already has flu comes into close contact with birds who have highly pathogenic bird flu, there is a tiny chance that the person could become infected with the bird flu virus. If this happens, the person would now be carrying both the human flu virus and the bird flu virus. The two viruses could meet in the person’s body and swap genes with each other³. In pigs- pigs are susceptible to both human and bird flu viruses. If a pig became infected with both viruses at the same time, it could act as a “mixing vessel”, allowing the two viruses to swap genes and produce a new virus. Has flu been passed between people? There are signs that it might have been. It seems to have been passed between a child and her mother in Thailand, and in a family in Vietnam². However, so far there has been no sustained human-to-human transmission i.e. it has not spread any further than between close family². Does this mean the human and bird flu viruses have merged? No. Scientists have not discovered an influenza type a (H5N1) virus that contains both human and bird virus genes. This means that the bird flu virus has not merged with the human flu virus². These isolated cases of person to person transmission may have been caused by the basic bird virus being passed on due to close contact⁴. What are the symptoms of bird flu in humans? In humans, bird flu causes similar symptoms to other types of flu: fever cough sore throat muscle aches conjunctivitis Severe cases of bird flu can cause breathing problems and pneumonia, and can be fatal. Are there any treatments available for bird flu? Antiviral medications used to treat human flu viruses help to reduce the symptoms of bird flu, but it’s not yet clear whether these work for the current type of bird flu¹. Is there a vaccine to stop people getting bird flu? There is currently no vaccine to prevent bird flu in humans. Currently available vaccines are not effective against the H5N1 strain of the virus. Scientists are working on developing a vaccine, but it is difficult because the virus frequently changes¹. What is the current advice for travellers to countries affected by bird flu? As of February 23rd 2005, countries affected by bird flu include Cambodia, China, Hong Kong, Indonesia, Japan, Korea, Laos, Malaysia, Thailand and Vietnam⁵. The advice for travellers to these countries is to avoid places where live poultry are raised or kept, such as poultry farms and bird markets, and to avoid contact with sick or dead poultry. Travellers are also advised to make sure that chicken eaten in affected countries is cooked thoroughly¹. What can be done to contain the spread of bird flu? In the countries that have been affected by bird flu, governments have begun to cull affected poultry stocks. By removing the potential for the virus to spread through the countries’ chicken populations, it is hoped that the virus will be contained and removed from circulation.

THESE DAYS, pharmaceutical companies must aim not just for efficiency but for effective marketing. Effectiveness can be defined as the achievement of a response in which the drug is adopted and prescribed. This realignment from efficiency to effectiveness parallels the NHS’s increasing focus on outcomes. Decision-making structures are changing Why is the old approach so urgently in need of an overhaul? One of the major reasons is that the structures of, and environment for, decision-making, are changing radically in the “new” NHS. For example, in general practice, doctors are by no means the only decision-makers; nurses and dispensary managers have their say as well. An estimated 28,000 district nurses and health visitors now have limited prescribing powers. In addition, there are 2,500 ’supplementary prescribers’ - a number that is expected to quadruple by the end of 2005. Hospital and community clinicians are accounting for a high proportion of prescriptions - incontinence nurses make most decisions about continence and stoma appliances, which are a significant element of spending. New roles, often associated with decision-making power, are emerging all the time. Pharmacists are increasingly positioned to influence the scripts that get written. The proposed new pharmacy contract would increase pharmacists’ role in ensuring that patients are compliant. For a drug like Lipitor, compliance can be far lower than expected. If pharmacists can increase compliance, the amount of prescriptions will increase. Pharmacists could also influence prescribing behaviour by identifying additional patients who might benefit from a treatment. Decisions Are Being Made At Different Levels Along with the proliferation of decision-makers, another complicating factor is that prescribing decisions are now being made at different levels of the NHS structure. Through the increasing use of formularies, drug choices are tending to be made collectively within a practice, rather than by individuals. Under the new GMS contracts introduced in April 2004, PCO (Primary Care Organisation) contracts are with a practice as a whole, rather than an individual practitioner - another reason to expect prescribing choices to be made at practice level. The public too are a source of pressure on prescribing. Through talking to friends, or from their own reading, television watching and internet research, patients are increasingly impelled to ask GPs for specific medicines. Adverse media reports may create patient resistance to a particular drug, just as reports of successful drug trials will create demands for it before it is on the market. OTC availability of drugs such as statins could cause problems down the line: patients may decide to buy these over the counter for the time being, then, on reaching 60, ask their GP for a prescription. This could pose a dilemma if the patient’s risk does not fall within the guidelines for prescribing, particularly as patients prescribed statins require monitoring, which costs money. Patient power is also manifested in the form of patient groups. The UK now has over 200 national patient groups and over 2000 patient support groups. The influence of these groups can be judged from the fact that the largest national group, the British Heart Foundation, has a budget of over £100 million. These groups engage in lobbying, for example in the context of NICE assessments. Some groups also fund specialist nurses, often in conjunction with industry. In both of these ways, as well as through their dialogue with individual patients, the groups may influence the choice of prescription drugs. All this adds up to a complex and demanding environment for healthcare decision-makers. What does it mean for pharmaceutical companies? The restructuring of healthcare decision-making implies that SOV-based approaches, however effective in conventional terms, may not reach those with the ability to respond as intended, that is by writing scripts. Even if the approaches do reach the right ears, decisions may be constrained by various external pressures. How the Industry Can Respond To become effective, as opposed to merely efficient, it is vital for the pharmaceutical companies’ marketing departments to know their new targets. In view of the rise of the practice formulary, and the new contracts between PCOs and practices, much promotion is going to have to occur at account, rather than at individual, level. Sales people need to fully appreciate the pressures and constraints their targets are working under. For instance, with GPs being encouraged to spend longer seeing each patient, there will be less time to see pharmaceutical company representatives. It is essential that the reps are ready to make the most of any time they get with decision-makers, by providing exactly the information that is needed, with an appropriate amount of detail. Parroting the detail sheets is not enough. GPs can get that information and more from published trial results or Internet sites such as doctors.net.uk. An example could be as to whether a practice has been involved in clinical trials, so the GP may have known about the drug before the rep did. There are a variety of strategies that some forward thinking Pharma companies have been exploring to ensure they put the right information in front of the right people. The ability to map networks of KOLs (Key Opinion Leaders) requires significant research, but repays the effort by enabling more effective targeting and segmentation. In the case of smaller companies, it is prudent to review vacant territory strategies, evaluating the difference between covered and vacant territories and then using lateral thinking to find alternative ways to cover important vacant territory (mailings, symposia and face-to-face calls with selected KOLs all being options). Consideration of influence networks and vacant territory strategies have led some companies to go for a complete restructuring of the sales force, or even its dismissal in favour of other techniques. Collaborative approaches, where the pharmaceutical company funds education or nurses, have proved a successful way to reach decision-makers, but may be beyond the reach of smaller companies. Technology can also help companies evolve and execute their new marketing strategy. Reformulating targeting and segmentation is made much easier if you can map networks of influence, backed by up-to-date databases that offer the ability to create profile and identify links between individuals. NHS decision-making processes can be hair-raisingly complex. To achieve marketing effectiveness in this new environment, it is essential for pharmaceutical companies to be able to identify the real decision-makers and approach them in the right way. There is a silver lining. Decisions will be longer term because of frameworks provided by formularies and so on. There will be fewer decision-makers overall, so provided you have the right information it is possible to target marketing approaches more accurately than ever before.